Flu-shot shortage in the US raises ethical questions

NY TIMES NEWS SERVICE , ATLANTA

Mon, Nov 22, 2004 - Page 7

The debate over who gets scarce flu vaccine begins with harsh reality. The most basic ethical principle is fairness. Almost 100 million Americans needed a flu shot this year. But contaminated vaccine meant short supply, so that even groups most vulnerable to flu may not get the shot. "Fair" is not possible.

The Centers for Disease Control and Prevention was charged with the unhappy job of distributing not enough vaccine. To help solve the ethical dilemma of who gets a shot, the CDC a month ago created a volunteer panel of medical ethicists. Kathleen Kinlaw, the associate director of the Center for Ethics at Emory University, and her colleagues on the panel are tackling the same question asked every day during flu season by doctors, nursing home administrators and public health nurses across the country: How do you decide -- and justify -- who goes first?

To answer it, the ethicists must weigh claims that seem equally worthy. "Do we provide immunization for an 80-year-old nursing home patient with dementia over a healthy 75-year-old who lives in the community?" Kinlaw asked the panel. "Equity is a principle that we have not met," she acknowledged. "Everything we do next proceeds from that recognition."

Questions from around the country pour into the CDC, which connects the ethicists for biweekly telephone consultations. Kinlaw outlined the challenges they review: choosing between the young and the elderly or the chronically ill and those caring for them, and knowing that a decision not to vaccinate could result in severe illness or death.

With contamination knocking out 48 million doses manufactured for this flu season by the Chiron Corp. -- half of the entire US' order for this year -- flu vaccine has never before been in such short supply. In previous years, including last year, vaccine deliveries arrived late, causing shortages across the country.

But in each of those years, including last year, there was eventually more vaccine than there were requests to be vaccinated.

Last spring, more than 3 million flu vaccine doses were returned to manufacturers unused. So far this season, about 8 million doses of injectible vaccine have yet to be distributed, out of the 61 million that the US has scraped together.

The gap between the number of those who need vaccine and the number of vaccine doses available has left doctors making anguished decisions. At Midtown West Medical, a small Atlanta practice with a high proportion of HIV-positive patients, Dr. Kimball Johnson has had to weigh the competing needs of young people with very fragile immune systems against elderly patients with chronic respiratory diseases and diabetes.

The practice did not receive any of the 1,000 flu shots it ordered. So far, it has cobbled together about 200 doses..

"It is so frustrating," Johnson said. "And it requires our having to make very complicated calculations.."